Life — is the main value on the earth.

For their safety and efficiency to be controlled, the pharmacovigilance system has been developed in order to increase liability of the corporation to its consumers for product quality and take timely and adequate measures to improve our products.

If you have got to know any information on any adverse reaction to or lack of efficacy of the medicinal products manufactured by Yuria-Pharm Pharmaceutical Corporation, please fill in the report form.

ADVERSE DRUG REACTION REPORT FORM

All information you provide to us is strictly confidential and shall not be disclosed unless otherwise prescribed by the law.

Report-form

about adverse reaction (AR) and/or lack of efficacy (LE) of the medicinal product (MP) during its medical use

І. GENERAL INFORMATION

Patient’s full name

Number

SexFemaleMale

Birth date

AE / IE commencement

AE termination

Description of the AE / Specification of IE of the MP

AE / IE CONSEQUENCE

recoveryin process of recoveryno changesunknownrecovery with consequencesdeath not related to the AEdeath probably related to the AEdeath related to the AE

AE / IE CATEGORY

patient’s deathlife threathospital admission of the outpatientextension of hospital admission long-termincapacity for work, disabilitycongenital defectsother important medical assessmentnothing of the above-mentioned

Report-form

for providing the patient and/or his representative, organizations representing the interests of patients, information on adverse reactions and/or lack of efficacy of the medicinal product during its medical use

INFORMATION ON THE NOTIFIER

Patient’s full name

SexFemaleMale

Birth date

Address

Tel./fax

E-mail

INFORMATION suspected medicinal product

Doctor’s full name

Name of the health care institution

Suspected drug was intended patient doctor

YesNo

The patient used a suspected drug without prescription

YesNo

Description of the adverse effect or specification of lack of efficacy

Notifier’s full name

Notifier’s full name

Location

Tel./fax

E-mail

INFORMATION ON THE DOCTOR / HEALTH CARE INSTITUTION

Doctor’s full name

Name of the health care institution

Location of the health care institution

Tel./fax

E-mail

Submission date: 07.06.2020

* ‒ compulsory fields

I consent to processing of my personal data

Report form about the MEDICAL DEVICE

at use/applying

INFORMATION ABOUT THE IDENTITY

Notifier’s full name

Informdoctornursepatientother

Location

Tel./fax

E-mail

CUSTOMER INFORMATION

Patient’s full name

Address

Tel./fax

E-mail

SUSPENDED MEDICAL DEVICE

Title of medical device

Manufacturer, country

Batch number

Description of message

Submission date: 07.06.2020

* ‒ compulsory fields

I consent to processing of my personal data

Sign for health professionals

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